* Required Field |
Date(yyyy-mm-dd): |
* |
Last Name : |
* |
First Name : |
* |
Partner’s Name : |
* |
Address: |
* |
City: |
* |
MA Zip Code: |
* |
E-Mail: |
* |
Cell: |
* |
Partner’s cell: |
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| List one relative or friend in case of emergency:: |
Name: |
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Phone: |
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Relation: |
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| Child's Name: Age Sex Birthdate mm/dd/yy Living at home? |
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| List other people living with you: (include Name, Sex, Age and Relationship) |
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| Do all of the members of your household agree to host a student? |
Yes
No |
| Why do you wish to host a student? |
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Occupation : |
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Partner's Occupation : |
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Name of Company: |
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Name of Company(partner): |
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Work Phone: |
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Work Phone(Partner): |
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Work Days/Hours: |
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Work Days/Hours(Partner): |
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Employment Verification Phone: |
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Partner's Employment Verification Phone: |
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| List Two Personal References (Not Relatives) |
Name: |
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Address: |
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City: |
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State: |
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Zip: |
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Phone : |
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Work Phone : |
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Name: |
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Address: |
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City: |
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State: |
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Zip: |
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Phone : |
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Work Phone : |
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| Homestay Family Application
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Language spoken at home: |
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Second Language: |
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What other countries have you visited?: |
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Have you hosted a student before?: |
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What Nationality?: |
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How many students do you wish to host at one time?: |
(Each student must have a separate room with a window, door, bed, dresser, closet, desk, chair and proper light for studying) |
Do you prefer: |
Male
Female
Either |
Countries: |
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May students put in a private phone?: |
Yes
No
(students pay their long distance charges) |
Will students have access to wireless Internet?: |
Yes
No
or a computer with Internet?
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Do you have a washer/dryer in your home?: |
Yes
No |
Do you have pets?: |
Dogs
Cats
Other
Inside
Outside |
Do you smoke?: |
Frequent
Seldon
Never |
Have you or any member of your family been convicted of a criminal offense?: |
Yes
No |
Would you allow smoking?: |
Yes
No if no, would you allow smoking outside?
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Do you drink alcoholic beverages?: |
Frequent
Seldon
Never |
Do you object to students (over 21) drinking?: |
Yes
No |
Do you mind students using the kitchen?: |
Yes
No |
| Transportation: Please check with the MBTA for the time between your
front door and downtown Boston. Including walking, riding, and waiting for transfers it should be less than 45 minutes.
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| Please write down the Public Transportation route from your house to downtown Boston |
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What time is the last bus/train to return to your home?: |
Weeknights
Weekends |
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| Hobbies and Activities: |
Do you have a musical instrument in your house?: |
Yes
No |
What Kind?: |
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Does your family prefer activities at home or away from home?: |
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| Please check the activities that your family enjoys. List choices and the family member that participates: |
| Sports Miscellaneous Family Activities |
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| Please add anything else that you think would help us to select the right student for you |
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Who may we thank for referring you to our program?: |
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I confirm that the foregoing information is true, and that I wish to be a Host Family. |
Signature of applicant Date 1: |
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Signature of applicant Date 2: |
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